Start Living again! after Obesity Surgery

written by Prof Dr Chin Kin Fah on 3 July 2013
In Malaysia, a developing country, the increasing prevalence of obesity and associated metabolic syndrome has created major healthcare problem due to the adoption of more westernized lifestyle and diet. Population surveys have found the prevalence of obesity has rapidly increased 3 folds in recent decade.
 
The National Health & Morbidity Study in 1996 and 2006 revealed that the prevalence of overweight (BMI 25-30) rose from 16.6% to 29.1%. The prevalence of obesity (BMI>30) increased from 4.4% to 14%. It was also showed our female population, ethnicity of Indian & Malay and house wife tend to be obese. It was noted the prevalence of diabetes mellitus in this population also increased from 8.3% to 14.9% with substantially portion of them undiagnosed. There is an estimated about 1.5 million diabetes patient (5.7%) which is a significant healthcare burden in Malaysia with a small population of about 26 million people in 2006.
 
Although the bariatric surgery has been prove to be costeffective treatment of obesity and associated co-morbidity especially DM, the adoption of this advanced surgery is still slow in Malaysia. Currently, only hospitals with qualified and experienced laparoscopic surgeon are routinely offering this procedure. The lack of surgical training opportunity, public awareness and no insurance coverage for obesity might be the factors that hinder the progress of this surgery. Lastly, we foresee, with the rising prevalence of T2DM affecting younger age group and the promising effectiveness of bariatric surgery as a form of metabolic procedure, the most cost effective therapy for early
obese T2DM should be surgery, as a first line modality in future. Obesity surgery started more than 50 years ago. Tremendous advances have been observed in this practice of surgery. New techniques, new procedures, minimally invasive access and improvements in preoperative management have transformed the system of obesity surgery into a subspecialty of its own. To date,there is no effective diet or drug therapy available to treat the morbidly obese.
 
On the other hand, bariatric surgery has been proven to be effective, providing marked and lasting weight loss,
ranging from 47.5%to 70.1% of excess body weight. These results are achieved in relative safety, with operative mortality equal or less than that for other major operative procedures (about 0.5%).The weight loss outcome, results in dramatic improvement on the co-morbid conditions of morbid obesity.
 
The major medical co-morbid conditions can be divided into those where reversal or improvement has been proven such as type 2 diabetes, hyperlipidaemia, hypertension, obstructive sleep apnea,etc and those where reversal or improvement are reasonable and presumed such as cardiac and peripheral vascular disease, incidence of thrombophlebitis and pulmonary emboli and various carcinomas.
 
The ameliorating effects of bariatric surgery are not limited to medical co-morbidities. Socially, quality of life is vastly
improved, as are body image, personal hygiene, and sexual activity. Many of the economic deprivations of the morbidly obese are reversed after marked weight loss due to increased employment opportunities advancement potential, and level of income. The sum total of these co-morbidity benefits is an increase in longevity.
2005 APBSG consensus meeting has modified the indication of bariatric surgery for Asian people to
 
1.Obese patients with their BMI over 37
2.Obese patients with their BMI over 32 in the presence of diabetes or other two significant obesity related co-
   morbidities.
3.Have been unable to lose or maintain weight loss by dietary or medical measures.
4. Age of patient > 18 years and < 65 years.
   * Under special circumstance and inconsideration with a pediatrician, bariatric surgery may be used in children
      under age18
 
2010 ADSS meeting in Taipei has proposed the indication of metabolic surgery for Asian diabetes people
 
1. Metabolic surgery should be recommended for diabetes patients with their BMI over 37
2. Metabolic surgery should be considered for diabetes patients with their BMI over 32 and not well controlled
    (HbA1c > 7.5%) after intensive medical treatment.
3. Metabolic surgery may be considered for diabetes patients with their BMI over 27 with many co-morbidities and not
    well controlled (HbA1c > 7.5%) after intensive medical treatment.
4. Age of patient > 18 years and < 70 years, with acceptable surgical risk and without end-organ damage.
    *The patient should be cared and followed by multi-discipline medical team and pre-operative B-cell function  
      evaluation is indicated  
 
Bariatric surgery is an extremely effective weight loss tool which can result in significant and sustained weight loss. Implementing a structured post-surgical dietary protocol and managing the nutritional deficiencies that can result from such surgery, are essential to any bariatric surgical practice.
 
There are 4 critical stages after bariatric surgery where dietary manipulation and intervention are essential for weight loss success.
 
1. Post-surgical healing phase (liquid diet) – enables healing to occur from the surgery and minimizes patient  
    discomfort whilst lessening the risk of stretching the new stomach pouch.
2. Progression of diet back to solids – semi-solid meals are introduced then gradual progression back to solid diet.
    The soft texture diet enables the stomach to get used to foods again, and the patient begins the learning process
    of howmuch they can safely eat.
3. Normal diet – dietary intervention during the longer time period from post- surgical period right through to target
     weight. Dietary guidance and regular contact with the patient is essential to continue a steady but adequate rate of
     weight loss and minimize nutritional deficiencies.
4. Maintenance of target weight – ongoing dietary review to ensure weight lost is maintained.
 
An experienced bariatric dietitian is a critical team member in each of these stages. The nutritional consequences of bariatric surgery must be considered on an individual basis, as both macronutrient and micronutrient deficiencies can occur. Deficiencies must be screened for and appropriate supplementation provided.